Graduate Application for Admission

BEFORE you can be admitted to the WOU Special Education Programs, you will need to complete and submit:

Application to the WOU Graduate School (print on green paper); with the $50 fee; the application form is available in PDF format at:

Complete and submit the Special Education Programs application form by the specified deadline:

You may complete the following form using a computer (.doc file) or in writing. Please send the completed application to:

Western Oregon University

Special Education Programs

ED 220 – 345 N. Monmouth Avenue

Monmouth, Oregon 97361

If you think your mailed application may miss the deadline, you have two options to submit your completed application – and please be sure to mail the application after you do one of the following:

you can fax the application to the College of Education fax number: 503-838-8228 – please write/print on the cover sheet: Attention: Special Education Programs.
you can e-mail the application as an attachment to:

NOTE:(a) The three (3) Confidential References MUST be mailed directly to the WOU Special Education Programs – you must NOT submit the completed reference forms with your application.

(b) Please have your official transcripts sent to the above address. Copies will be made for your Special Education file and then sent to the Graduate School.

Page 1

Date of Application: / Beginning year: / 20
Program(s) to be completed:
Master’s Degree / License/Endorsement / Special Educator
EI/ECSE

Please print clearly or type the following –you may attach additional pages if you need more space – please use the appropriate title(s) on the additional sheet(s):

Last name / First name / Middle name / Previous name, if any
Social Security Number: / Present Position:
Permanent Address:
Street / Apt # / PO Box
City / County / State / Zip
Current Mailing Address:
(if different from above) / Street / Apt # / PO Box
City / County / State / Zip
Phones:
Home / Work / Cell
Email Address 1:
Email Address 2:
NOTE: / Completion of the information in this section is optional and will be used for statistical reporting purposes only. Your decision to complete this section will not affect consideration of your application.
Date of birth (optional) / Gender: / Male / Female
YYYY – MM – DD
Race/Ethnicity: / Caucasian / White / Hispanic / Asian / Pacific Islander
African American / Native American / Alaskan Native / Undeclared
Do You Have a Disability? / Yes / No / Are you a Veteran? / Yes / No
Language Proficiency: / English / Speak & Understand / Read / Write / I am bilingual
Put a “√” in the box if applicable
Spanish / Speak & Understand / Read / Write / I am bilingual
Specify Language / Speak & Understand / Read / Write / I am bilingual
Specify Language / Speak & Understand / Read / Write / I am bilingual
If there are scholarships to support bilingual students, do you want to be
considered for such scholarships? / Yes / No

Degree(s) currently held:

NOTE: Please attach a photocopy of your transcripts from the school(s) where you earned your degree(s). The WOU Graduate School will only accept official transcripts. Please have official transcripts sent directly to the WOU Graduate School.

Degree

/ University / Year Awarded / Major / Minor

Teaching License(s)/Endorsement(s) held: Complete the following and send a photocopy of your most recent Oregon teaching license to the WOU Special Educator Program (see address on this webpage):

Licenses/Endorsements Held / State / Date Issued / Date Expires

Please check ( √ ) the following tests you have taken and attach complete copies of your score report(s): (NOTE: Prospective students are required to have passed either the CBEST or PPST Praxis I test or be registered to take the test prior to the start of the program.)

√ /

Test

/ Scores: / Reading / Mathematics / Writing / (Most Recent)
Date taken
CBEST
PPST - Praxis I (Pre-professional Skills Tests)
Praxis II – Specialty areas(specify) / Test / Score
Test / Score

Educational History: List college(s) attended, date of degree, major and minor (if applicable). Indicate date of anticipated receipt of degree you are now working on. Attach copy of most recent transcripts for each school listed.

College / Dates Attended / Major / Minor / Degree and
Date Awarded

Grade Point Average:

Undergraduate cumulative grade point average / on a / point scale
Current graduate grade point average: / on a / point scale
Special Education courses grade point average / on a / point scale
(if applicable)
GPA of last 90 hours upper division courses / on a / point scale
(e.g., courses numbered 300 & above)

Academic Honors, Scholarships, Awards: List all academic honors, prizes, scholarships or awards you have received during your college or professional career (attach additional pages if needed).

Award Name / Awarded by / Month & Year

Employment History: Itemize all paid employment including part-time work (last five years or most recent):

Date
Position / Employer / Duties / From
mm/yy / To
mm/yy / Reason for Leaving / Name and Contact Information for Supervisor

Supervised Teaching/Field Experiences:List supervised field experiences completed (e.g. student teaching, clinic, and practica).

Describe Type of Field Experience / Location (city, state) / Population with Whom You Worked / Ages of Students/Clients in This Setting / Name and Contact Information of Supervisor

Leadership & Volunteer Experiences: List extra-curricular activities in college or community that would show involvement and leadership. Include volunteer experiences.

Activity / Duty / Agency & Location / Supervisor / Time Involved

Confidential References: Please list below the names and addresses of the three(3) current and/or former professionals you will ask to complete and submit a Confidential Reference form.

Note: Each completed Confidential Reference formmust be sent in a sealed envelope directly to the WOU Special Education Programs by the individual providing the recommendation.

Name / Position / Address / Phone Number / E-mail

Professional Goals: What are your immediate and long-range professional goals after you have completed your academic preparation? Include the degree of certainty of serving in the field for which this application is made. Please write in paragraph form (attach additional paper if needed).

Immediate (1-5 years):
Long-Range (6-10 years):

I certify that the information provided above is true. I also understand that the Applicant Recommendations under References are confidential and must be sent in a sealed envelope directly to the WOU Special Educator Program by the individual providing the recommendation.

Signature: Date:

Send or take your completed application to:

Western Oregon University

Special Educator Program

ED 220 – 345 N. Monmouth Avenue

Monmouth, Oregon 97361

Phone:503-838-8322 or 838-8324

Fax:503-838-8228

CHARACTER QUESTIONS

You must answer each question either "yes " or "no" whichever is true. Explain each "yes" answer in detail on a separate sheet.

1. / Have you ever left any educational or school-related employment, voluntarily or involuntarily, while the subject of an inquiry, review or investigation of alleged misconduct or alleged violation of professional standards of conduct or when you had reason to believe such investigation was imminent? / 1.
2. / Are you currently the subject of an inquiry, review or investigation for alleged misconduct or alleged violation of professional standards of conduct? / 2.
3. / Have you ever failed to complete a contract for educational services in any educational or school-related position, or for any alleged misconduct or alleged violation of professional standards of conduct been placed on leave by your employer or left such employment prior to the end of the contract term? / 3.
4. / Have you ever had a professional certificate, credential or license (of any kind) revoked or suspended or have you been placed on probationary status for any alleged misconduct or alleged violation of professional standards of conduct? / 4.
5. / Have you ever been denied a professional license for which you applied or granted a professional license on a conditional or probationary basis for any alleged misconduct or alleged violation of professional standards of conduct? / 5.
6. / Have you ever surrendered a professional license of any kind before its expiration? / 6.
7. / Have you ever been disciplined by any public agency responsible for licensure of any kind, including but not limited to educational licensure? / 7.
8. / Have you ever been convicted or been granted conditional discharge by any court for: (a) any felony; (b) misdemeanor; or (c) any major traffic violation, such as: driving under the influence of intoxicants or drugs; reckless driving; fleeing from or attempting to elude a police officer; driving while your license was suspended, revoked or used in violation of any license restriction; or failure to perform the duties of a driver or witness at an accident? / 8.
9. / Have you ever been arrested or cited for any offense listed in question (8) above which is still pending in the court? / 9.
10. / Have you ever entered a plea of Guilty or No Contest relative to any charge for an offense listed in question 8? / 10.
11. / Have you ever had any civil judgment or other court order entered against you resulting from abuse, assault, battery, harassment, intimidation, neglect, stalking, or other threatening behavior toward other persons? / 11.
NOTES: / 1. / Any false statement knowingly made in this application is grounds for revocation or suspension of your license. If in doubt, disclose and explain rather than conceal. If you answer “no” to questions 8 through 11 based upon an “expungement” order, “setting aside” or “sealing” of a record of a conviction or conditional discharge, you must personally verify with the court directly involved that the expungement, setting aside or sealing actually has taken place. An erroneous belief that a conviction has been expunged, set aside or sealed, when in fact it has not, will be deemed a false statement.
2. / If you answer “yes”, a certified true copy of the court records must accompany this application (if not previously submitted to TSPC).

Signature and the Date

I hereby certify that the information submitted on or relating to this form is true and correct and grant the Commission permission to check civil or criminal records to verify any statement made on this application. The Commission may deny or revoke permission for student teaching or final practicum upon evidence that I knowingly made any false statements on this form. I also grant the Commission permission to release any information related to these character questions to the institution supervising my practicum, internship and/or student teaching.

Signature of the student teacher or practicum applicant / Date

PA-dl/1/25/06

Page 1

CONFIDENTIAL REFERENCE FORM

To the Applicant:Please fill in the information in the box below and then give each of the three Confidential Reference Forms to a different current or former supervisor / colleague and ask him/her to complete and sign it.

Applicant’s Last name / First name / Middle name / Previous name, if any
Program(s) to be completed:
Master’s Degree / License/Endorsement / Special Educator
EI/ECSE

To the Reference:This Applicant Reference Form is confidential and must be sent in a sealed envelope directly to the WOU Special Educator Program by the individual providing the reference. Please print clearly or type the following –you may attach additional pages or write on the back of this form if you need more space.

In what capacity and for how long have you known this applicant?
Exceptional (Top 5%) / Excellent (Top 15%) / Average or above / Below Average / Poor (Bottom 15%) / No opportunity to observe
1. / Degree of mastery of the fundamental knowledge in the field.
2. / Ability to use effective techniques basic to the field.
3. / Degree to which applicant displays imagination and originality in the field.
4. / Ability to express self in speaking.
5. / Ability to express self in writing.
6. / Degree of success in interpersonal relations with staff.
7. / Ability to develop rapport with children/youth/clients.
8. / Professional growth during the period you have observed the applicant.
9. / Motivation toward achieving a successful career as a special educator.
10. / Ability to manage learning environment and student/client behavior.
11. / Degree of emotional stability and maturity.
12. / Degree to which applicant seeks own answers through independent research & thinking.
13. / Summative Evaluation: Your estimate of the applicant’s overall ability to do work in the field and the level selected.
14. / Applicant’s greatest strength(s):
Applicant’s greatest need(s)/challenge(s):
15. / Please add descriptive comments that will assist in providing a complete picture of the applicant’s abilities and potential to do high quality study. Please write or type additional comments on the reverse side of this page.
Reference’s Signature / Date
Reference’s Full Name (type/print) / Title / Work Phone / Cell Phone
Reference’s Full Address / Employer/School/District / Preferred E-mail

Page 1

CONFIDENTIAL REFERENCE FORM

Applicant’s Last name / First name / Middle name / Previous name, if any
Program(s) to be completed:
Master’s Degree / License/Endorsement / Special Educator
EI/ECSE

Page 1

CONFIDENTIAL REFERENCE FORM

Applicant’s Last name / First name / Middle name / Previous name, if any
Program(s) to be completed:
Master’s Degree / License/Endorsement / Special Educator
EI/ECSE

Page 1